Vaginitis

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Vaginitis Main Page

Patient Information

Overview

Classification

Bacterial Vaginosis
Candida vulvovaginitis
Trichomonas infection
Atrophic Vaginitis

Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2], Dima Nimri, M.D. [3], Aravind Kuchkuntla, M.B.B.S[4]

Overview

Vulvovaginitis, a common condition for which women seek medical care, accounts for greater than 10% of visits made to providers of women's health care.[1] It is characterized by symptoms that cause itching, irritation, burning, and abnormal vaginal discharge. The three most common causes of vaginal discharge in women within the reproductive age group are bacterial vaginosis, candida vulvovaginitis, and trichomoniasis. All patients with vulvovaginitis present with common symptoms like vaginal discharge, itching, and dysuria. Diagnosis of vulvovaginitis requires a detailed history of the patient's symptoms, as well as her sexual history, both of which facilitate an accurate diagnosis. Physical examination of the external genitalia and speculum examination should focus on documenting the nature of the discharge, the presence of any vulvar or labial lesions, foreign body, presence of cervical inflammation, cervical lesions, and any cervical motion or adnexal tenderness with a bimanual examination. It is essential to rule out pelvic inflammatory disease and cervical lesions as the cause of vaginal discharge. Estimation of vaginal pH and vaginal smear wet mount examination constitute the initial diagnostic test, which helps differentiate among common etiologies. Treatment of vulvovaginitis includes medical therapy targeted against the causative pathogen and counseling on hygiene, voiding techniques, and sexual practices. The prognosis is good in most patients, though a minority of patients experience recurrence.

Classification

Based on the etiology vaginitis is classified into the following:

Differential Diagnosis

The differential diagnosis for patients presenting with vaginal discharge includes the following considerations:

Common Presentation Disease Symptoms Physical Examination Findings
Discharge Dysuria Vaginal odor Dyspareunia Genital skin lesion Genital pruritus
Vaginitis Candida Vulvovaginitis ✔✔
Bacterial Vaginosis
Trichomoniasis
Atrophic Vaginitis ✔✔
Aerobic Vaginitis
Cervicitis Chlamydia
Gonorrhea

Diagnosis and Treatment

The following table summarizes the diagnosis and management of common vaginitis conditions:[4]

Disease Investigation Diagnostic Approach Treatment
pH Saline Wet mount preparation Gold Standard test
Candida Vulvovaginitis Normal Hyphae and pseudohyphae can be demonstrated Culture
  • In patients with normal pH and positive microscopy, culture is not neccessary and treatment can be initiated
  • In patients with normal pH and negative microscopy, culture for candida is done
  • Topical Azoles for uncomplicated infection
  • Oral Fluconazole one dose of 150mg for complicated infection
Bacterial Vaginosis >4.5 Clue cells are demonstrated Gram stain to determine the relative concentration of lactobacilli, Gardnella vaginalis, Prevotella, Porphyromonas, peptostreptococci and Mobiluncus

Amsel’s criteria: Presence of three out of four criteria is required to make the diagnosis of Bacterial Vaginosis

  • Vaginal fluid pH >4.5
  • >20% of “clue” cells (cells with unclear borders, dotted with bacteria)
  • Milky homogenous, adherent vaginal discharge
  • Positive “whiff” test, which is an amine or “fishy” odor noted after the addition of 10% potassium hydroxide
  • Correlation of the criteria and gram stain is performed to confirm diagnosis
  • Metronidazole 500 mg orally twice a day for 7 days OR
  • Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days OR
  • Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
Trichomoniasis >4.5 Nucleic acid amplification test (NAAT)
  • NAAT is highly sensitive for the diagnosis of trichomonas vaginalis.
  • Treatment is initiated after confirmation of the diagnosis
Atrophic Vaginitis Normal Vaginal smear cytology shows increased parabasal cells Leftward shift of the vaginal maturation index
  • Diagnosis requires the correlation of clinical presentation and vaginal cytology findings.
  • Other causes causing atrophic changes in the vagina should be ruled out.
  • Lubricants and moisturizers for mild symptoms
  • Topical or oral estrogen therapy for moderate to severe symptoms
Aerobic Vaginitis Increased

>6

Numerous leukocytes are present No gold standard confirmative test but excessive growth of aerobes on culture helps in diagnosis when the vaginal smear findings are indeterminate Microscopic diagnosis is made by Lactobacillus grade (LBG) and the severity is scored based on number of leukocytes, proportion of toxic leukocytes and parabasal epitheliocytes, and background flora

References

  1. Quan M (2010). "Vaginitis: diagnosis and management.". Postgrad Med. 122 (6): 117–27. PMID 21084788. doi:10.3810/pgm.2010.11.2229. 
  2. Miller KE (2006). "Diagnosis and treatment of Chlamydia trachomatis infection.". Am Fam Physician. 73 (8): 1411–6. PMID 16669564. 
  3. Chlamydia CDC Fact Sheet. CDC.http://www.cdc.gov/std/chlamydia/stdfact-chlamydia-detailed.htm#_ENREF_3. Accessed on January 11, 2016
  4. Workowski KA, Bolan GA, Centers for Disease Control and Prevention (2015). "Sexually transmitted diseases treatment guidelines, 2015.". MMWR Recomm Rep. 64 (RR-03): 1–137. PMID 26042815. 

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